Synopsis The Hili-Kum departed from an anchorage off Moresby Island, B.C., with a cargo of red urchins for discharge at Port Edward, B.C. En route, the weather deteriorated. On 10 April 1995, in following gale- to storm-force winds and rough seas, the vessel shipped large volumes of water on the afterdeck, settled by the stern, and sank stern first. The three crew members donned immersion suits, abandoned the vessel, and boarded a liferaft. Two of the three immersion suits were defective, and the liferaft capsized several times. Two of the crew succumbed to hypothermia and drowned; the survivor was rescued some five and a half hours later. The Board determined that the Hili-Kum proceeded to sea despite a storm warning broadcast, and was being operated in following high winds and rough seas with the fish hold hatch cover not battened down. The cumulative effect of large volumes of seawater shipped on the afterdeck, the vessel's low freeboard aft, and the flooding/downflooding of the below-deck spaces aft caused the vessel to settle by the stern, lose reserve buoyancy, and sink stern first. The hypothermia and subsequent drowning of two of the crew is attributable to the poor state of repair of their immersion suits and to their exposure to the harsh weather conditions when the liferaft capsized. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The wooden fishing vessel Hili-Kum was carvel built and of closed construction. The hull was divided into three watertight compartments by transverse bulkheads located at the forward and the after end of the fish hold. The accommodation/wheel-house was situated forward of amidships and included the galley, skipper's stateroom, and head. The crew accommodation in the forecastle was accessed through the engine-room. The general work area was aft. The vessel was utilized as a packer at the time of the occurrence. Abaft the accommodation, there was a fish hold and a lazaret. Access to the lazaret was by way of a watertight deck scuttle installed flush on the main deck. The lazaret was fitted with a pipe to drain water directly into the shaft space bilge. 1.2 History of the Voyage After hull repairs were completed, the Hili-Kumdeparted Shearwater, B.C., on 08April1995. Later that day, the vessel arrived and anchored in a small unnamed cove nearHot Springs, Moresby Island. The following day, the vessel loaded about 14,000kg of red urchins in the hold and on the afterdeck and was moderately trimmed by the stern. She departed anchorage at about 2200(3) for Port Edward with the stabilizers deployed. The weather and sea conditions were described as poor, with south-easterly winds at 35knots (kn) gusting to 45kn and 2 to 3mseas. By 0125, the winds had increased to 45kn gusting to 50kn, and seas of up to 7m were recorded. The vessel was heading on a course of 350magnetic (M) and shipping large volumes of seawater on the afterdeck. The crew observed a change in the vessel's motion and realized that the stern was settling deeper into the water. The skipper reportedly switched on the electric bilge pumps from the bridge and sent the cook/deck-hand (hereinafter referred to as the cook) to the engine-room to retrieve the immersion suits. When the cook entered the engine-room, no water was visible in the bilge. The cook picked up three immersion suits. He donned one while the skipper and the deck-hand donned the others. The zipper to the cook's suit was functional, but the zippers to the two other suits were defective. The cook transmitted a MAYDAY message at 0128 on channel 16 of the very high frequency radiotelephone (VHFR/T) advising the Marine Communications and Traffic Services (MCTS) Centre at Prince Rupert that the vessel was taking on water by the stern about 20 miles east-south-east (ESE) of Sandspit. The skipper and the deck-hand climbed up on the cabin roof and lowered the inflatable liferaft on to the foredeck. By this time, the vessel's stern was awash. At about 0152, the skipper advised the MCTS Centre that his crew and he were abandoning the vessel into a six-person inflatable liferaft, and he shut down the main engine. The cook and the deck-hand picked up some ship's handheld distress signals and proceeded to the liferaft. The skipper pulled on the painter to inflate the liferaft, but he had to tug on it several times before the liferaft inflated. The crew launched the liferaft and all hands abandoned the vessel into the water. They climbed into the liferaft and cut the painter, and the liferaft drifted away. Some five minutes later, at about 0230, the Hili-Kum sank stern first. Some time later, the liferaft capsized and the crew crawled out of the canopy, and climbed on to the overturned liferaft. The skipper and deck-hand did not know how to turn it over, but the cook, who had received survival training, was able to right the liferaft single-handedly. He then boarded the liferaft and proceeded to assist the others, but they were unable to hold on to the lifeline, and the liferaft drifted away in the strong winds. 1.3 Search and Rescue Throughout the night, the cook periodically saw the searchlights of surface units approaching the liferaft, but his attempts to attract attention using handheld flares were unsuccessful. The liferaft capsized several times throughout the night, but each time the cook was able to right the raft and reboard it. He was rescued by the United States Rescue Helicopter 6021 at 0815, 10April 1995, and transported to the Queen Charlotte City Hospital. The search continued and the body of the skipper was recovered still wearing an immersion suit. SAR units recovered an identical suit in the area some time later. However, the deck-hand was not found. 1.4 Injuries to Persons When rescued, the survivor was suffering from exhaustion and hypothermia, and had sustained a broken nose, and minor neck and back injuries. He was taken to a hospital, treated, and later released. An autopsy determined that the skipper had succumbed to hypothermia and drowned. The deck-hand is still missing and is presumed drowned. 1.5 Vessel Certification The then Ship Safety Branch of Transport Canada (TC), now TC Marine Safety, had inspected the Hili-Kumin March1992 and issued a Ship Inspection Certificate (SIC29) valid for a full term and due to expire in March 1996. The certificate limited the operation of the vessel to Home-trade, classIII voyages not more than 20 miles offshore. At the time of the last inspection, the attending inspector had not been informed by the owners or their representative that the vessel leaked and that the float-operated automatic bilge pumps were in almost constant use when the vessel was operating in rough seas. 1.6 Personnel Certification and Training Crew certification is not required on fishing vessels of less than 100 tons gross tonnage such as the Hili-Kum. None of the crew was certificated. There is at present no regulatory requirement for uncertificated crews of fishing vessels to undergo Marine Emergency Duties (MED) training. The program provides training in life-saving, abandonment, fire-fighting, and first aid with the use of appropriate equipment. The cook had taken survival training in the Canadian Navy; the other crew members were not knowledgeable in emergency procedures, nor had they undergone MED training. Further, no emergency drills had been conducted on the Hili-Kum. 1.6.1 Personnel History The skipper had 25 years' experience in the fishing industry. He had been an owner/operator of trollers and gillnetters for many years. He had leased the Hili-Kum in January 1995. The cook had been engaged in the fishing industry since 1992. This was his first trip on theHili-Kum. The missing deck-hand was an experienced fisherman who had fished with the skipper for a number of years. He had joined this vessel in 1995. 1.7 Stability Requirement The Hili-Kumhad not been inclined and no stability data had been generated. There was no regulatory requirement for such data. No stability data was available from any source to permit stability analysis nor were the vessel's plans available. The vessel had been in service since 1939, and there is no information to suggest that her stability was questionable. 1.7.1 Recent History of Vessel's Flooding There is conflicting information with respect to the condition of the vessel's deck and hull. According to a shipyard where work was carried out in January 1995, the hull was in need of caulking and refastening, and the afterdeck was in need of replacement. A deck-hand who joined the vessel in February 1995 reported that the overall condition of the Hili-Kum was poor: the deck leaked, the bulwarks were loose, and there was a leak in the hull that could not be located. In early March 1995, the vessel experienced severe flooding problems while alongside the dock at Port Edward. The skipper awoke to find that about 30cm of water had accumulated in the engine-room bilge. The water was pumped out, but, reportedly, the source of the ingress could not be located. On 19March 1995, the vessel experienced flooding problems off Banks Island, B.C., and additional pumps had to be placed on board to pump out the water. Following that incident, the vessel was dry-docked at another shipyard and the deck seams were filled and payed with boatlife. When the vessel was refloated, the only leak observed was the one in way of the shaft which had been there historically. At this time, a float-operated bilge pump was installed in the shaft tunnel. The cause of the historical leak in the vicinity of the shaft was never established and, consequently, was never addressed. 1.7.2 History of Repairs Reportedly, carrying urchins on deck had scraped the paint and caused superficial damage to the deck caulking. The owners had contemplated fibre-glassing the deck as a means to resolve the problem. The repairs to the vessel included the following: 1978 Forefoot and hull planks repaired. 1982 Hull completely caulked and motors replaced. 1992 Twelve planks including false keel replaced (Ship Inspection), hull recaulked, and keel cooler pipes repaired. 1995 Stern bearing renewed; rudder, shaft and propeller replaced; deck recaulked; and hull refastened and recaulked as necessary. The owners did not notify TC Marine Safety of the 1995 repairs. The regulatory authority was made aware of the vessel's flooding. The manager of the Cove Island Boatworks reportedly brought the vessel's inferior condition to the attention of a TC Marine Surveyor; however, there is no record of this report at TC Marine Safety nor does the surveyor have any recollection of such information. No inspection of the vessel was carried out. 1.8 Fish Hold Lining and Drainage In May 1993, the hold of the Hili-Kum was divided longitudinally and converted to two insulated fibre-glassed compartments to meet the requirements of the Fisheries Inspection Act. To remove any excess water from the holds, a pump in the engine-room had to be manually activated from either the engine-room or the afterdeck. 1.9 Hatch Securing Arrangement 1.9.1 Watertight Opening and Hull Any breach in the watertight integrity of the hull vitally affects the seaworthiness of the vessel and, consequently, the safety of the crew. Despite Ship Safety Bulletins Nos.1/83, 4/87 and 16/92, the practice of keeping watertight openings unsecured when not in use continues. The Board, concerned with this practice, previously recommended that the Department of Transport develop and implement measures to ensure that effective training and procedures are in place to preserve the watertight integrity of the hull(4). 1.10 Bilge Pumps 1.11 Loading Arrangement Urchins were then loaded on the afterdeck, starting at the aftermost end (working forward) and extending up to the middle of the hatch cover. They were stowed to a height of about 1.8m and covered with nylon tarpaulins which were secured to the vessel's rail. The skipper was aware that a storm warning was in effect for the area and decided to leave an additional 4,500kg of urchins behind. 1.12 Weather Information 1.12.1 Forecast The marine weather forecast issued by the Pacific Weather Centre of Environment Canada for the area called for south-easterly gales as early as 1745 on 08April 1995. Gale warnings were first issued at 0545, 09April and upgraded to storm warnings at 1745. South-easterly winds of 40kn to storm-force 50kn, with seas of up to 6m, were forecast. Stronger winds of55kn were forecast for 10April. 1.12.2 Weather Recorded The weather recorded by recording stations is consistent with that encountered by the vessel. At 1800 on 09April, the Sandspit Airport recorded south-easterly winds of 20kn, which increased to gales of 34kn at 2230, and then peaked to gales of 46kn with gusts of up to60kn at 0318 on 10April. The Environment Canada buoy (46183) located 32 miles north-east of Sandspit measured wave heights of 1m at 1700 on 09April, which gradually increased to 2.5m by 0130 on 10April, and rose to 6.2m by 0928 on 10April. During SAR operations, the Department of Fisheries and Oceans vessel TANU recorded seas of up to 15m and wind speeds of up to 70kn. 1.13 Risk-taking Fishing, in general, is a high-risk occupation, and the traditional attitude of the fishermen is to accept the risks involved(5). Threats posed by the hostile environment are often down-played. In this instance, the skipper, who was under financial pressure, proceeded from anchorage despite a forecast of bad weather conditions and without battening down thehatches. 1.13.1 Risk Assessment When people successfully perform a risky act on-the-job, they often change their attitude or opinion about the personal risk involved. They tend to discount the risk and come to believe that the activity is not risky, or they tend to develop a sense of their own invulnerability. The more often they are successful at the dangerous act, the more likely they are to believe that, although the practice may be dangerous in a general sense, nothing bad will happen to them. This attitude can lead them to repeat the act, and a vicious circle can be set up. The more often they do it, the more they feel justified in their sense of invulnerability. The more comfortable they become with the sense of invulnerability, the more likely they are to reduce the safety margin and engage in riskier behaviour.(6) It is ironic that, as the subjective evaluation of personal risk decreases, the odds of an accident happening are actually increasing. 1.13.2 Decision to Sail Sea urchins are a perishable product, and it is the skipper's responsibility to ensure that they reach the processing area in good condition and as quickly as possible. The Hili-Kum was smaller than the other urchin packers operating in the area. The vessel, therefore, had to make three trips to the other vessels' two to receive a fair share of the product. The skipper was under financial pressure to pay his crew and the vessel owners. He had fallen behind in payments on a loan co-signed by his father. The skipper had leased the boat since December 1994. He was known as a producer and often sailed in poor weather when other skippers remained in port. Although aware of the bad weather forecast, he elected to sail. The owners were in the process of obtaining a larger, more modern packer for the skipper tooperate. 1.14 Life-saving Equipment The life-saving equipment on the Hili-Kumincluded six lifejackets, a six-person inflatable liferaft, and three immersion suits. 1.14.1 Inflatable Liferaft The inflatable liferaft is required to be serviced annually by an accredited service depot. The validity of the SIC29 issued to the Hili-Kumwas contingent upon meeting this requirement. The onus is on the owners to ensure that the required servicing is carried out. TC Marine Safety has no regime in place to ensure that liferafts do undergo the mandatory annual servicing. Servicing History of the Liferaft The six-person, SOLASB-type liferaft was manufactured by Beaufort (Air-Sea) Equipment Ltd. in the United Kingdom in October 1973. A perusal of the liferaft log shows that, during the 23 years' service of the liferaft, it had been serviced five times: in May1978, July1983, June1988, August1989, and February1992; the last three servicings were in the presence of a ship inspector from TC Marine Safety. Requirement for Compliance with Canadian Standards In 1973, there was no liferaft manufacturing facility in Canada. Hence, all liferafts in use were imported. Only liferafts manufactured on or after 01July 1986 are required to comply with the new standards, which call for larger-size water pockets. Those manufactured prior to that date were permitted to remain in service until scrapped, as long as they met the original standards. There is no requirement for subsequent stability tests, and no maximum limit is set for a liferaft to remain in service. The water pockets on the liferaft in use were smaller than those required by the current standards. The liferaft, which was fitted with small water pockets, capsized about a dozen times. Reportedly, the tendency for the liferaft to capsize diminished somewhat when the single occupant was positioned away from the door toward the centre of the liferaft. The cook single-handedly righted the liferaft several times, and was exhausted by the time he wasrescued. The regulatory minimum length of the liferaft painter is 15m, and some manufacturers use a minimum length in excess of this requirement. The inboard end of the painter is connected to the pull/operating cable which activates the (non-toxic) gas cylinder, which inflates the liferaft. The whole length of the painter has to be hauled out of the canister before the liferaft can be inflated. In this instance, the liferaft was inflated on the foredeck. The skipper, after hauling the long length of the painter, had to give several hard tugs before the inflation process commenced. The survivor expressed dissatisfaction about the time required to haul the length of the painter. Neither the skipper nor the deck-hand knew how to right the capsized liferaft. Further, the crew did not inflate the floor of the liferaft, and they did not close the entrance cover to provide insulation from the cold as they were fearful of becoming trapped within the liferaft when it capsized repeatedly. 1.14.2 Immersion Suits - Regulatory Requirement There is no mandatory requirement for vessels of this size and type to carry immersion suits under the regulations made pursuant to the Canada Shipping Act. However, the Workers'Compensation Act of British Columbia, Fishing Operations Regulations which came into effect 01January1995 stipulate, under Section31(1), that every fishing vessel must carry, for each crew member, one immersion suit meeting standards acceptable to the Board. The skipper carried three immersion suits for his crew, all of which were stowed in the engine-room. 1.14.2.1 History of the Immersion Suits The date of manufacture of the immersion suits could not be established. The skipper of the Hili-Kum owned three immersion suits, which he had purchased in April 1978 for use on the fishing vessel ROGERS PASS. That vessel sank in November 1978 in Zeballos, B.C., with the immersion suits on board. The suits were not recovered until the vessel was salvaged in April 1979. It could not be confirmed if any maintenance had been done on the immersion suits after they were recovered. When the Hili-Kumwas leased, the skipper took two of these suits and one immersion suit, with the name RAMPANT stencilled across the back, on board. This last suit, he had borrowed from a friend. 1.14.3 Assessment of the Life-saving Appliances by the Department of National Defence (DND) After the occurrence, the liferaft was visually inspected prior to inflation testing, and the findings drawn included the following: the canopy half section was pulled away from a glued seam; the interior light was unserviceable, possibly due to the cable run being damaged; some canopy entrance door fasteners were missing; the canopy exterior coating was delaminating and sticky, and some righting straps were missing; the conduit for the firing cable was kinked some three inches from the body. A straight pull proved difficult, but was easier by the third tug, suggesting the presence of salt crystals or corrosion under the firing head disk. Post-occurrence inspection of the three immersion suits revealed that: the suit worn by the survivor was in good condition and appeared to be of newer construction than the other two suits, which were in fair condition; the zippers on the two victims' suits were unserviceable. On one of them, the slider assembly was separated from one side, frozen in the up position, and missing numerous teeth. The corrosion found on the sliders and zippers of those two suits is consistent with exposure to salt water and lack of lubrication or maintenance; all suits exceeded the buoyancy test requirements set forth in the standards(7). 1.14.4 Survival Skills and Marine Emergency Duties (MED) Training The Board, concerned that the lack of knowledge and skills regarding life-saving equipment and survival techniques on fishing vessels reduces the fishermen's chances of survival in emergency situations, has recommended that the Department of Transport ensure that fishermen receive formal training in life-saving equipment and survival techniques(8). TC Marine Safety has been consulting with the fishing industry to reduce to 15 gross tons the tonnage for fishing vessels required to have a certificated master, and it is envisaged that certificated masters of fishing vessels will receive MED training. However, crews, in general, will not be required to acquire survival skills. 1.15 Distress Signals When the crew sighted the searchlight of a vessel at about 0315, they activated two of the distress signals from the Hili-Kumwithin a period of about 10minutes, but the signals went unnoticed. The remaining distress signals that had been brought aboard the liferaft were lost overboard when the liferaft capsized. Some time later, the cook, by then the lone occupant of the liferaft, saw the searchlight of a vessel. He activated three of the six handheld flares from the liferaft kit, but they too went unnoticed. The remaining liferaft distress signals were lost overboard in subsequent liferaftcapsizings.